Extension for iliac branch delivery device and methods of using the same

ABSTRACT

Methods for accessing the common and internal iliac arteries and delivering and deploying an endovascular graft therein are disclosed. A system including a pre-loaded delivery and deployment device with an extension sheath is described which enables such a method to be practiced is also disclosed.

BACKGROUND

This invention relates generally to medical devices and methods of using the same, and more particularly, to an endovascular stent graft delivery device and methods for placement and deployment of the graft in the lumen of a branched vessel such as an iliac artery.

Stent grafts may be inserted into an anatomical vessel or duct for various purposes. For example, stent grafts are used for treatment of vasculature in the human or animal body to bypass a repair or defect in the vasculature or to maintain or restore patency in a formerly blocked or constricted passageway. For example, a stent graft may extend proximally and/or distally away from a vascular defect, including a diseased portion of an aneurysm, and engage a healthy portion of a vessel wall. In many cases, however, such a damaged or defective portion of the vasculature may include a branched or side vessel such as a common iliac artery and/or an internal iliac artery extending from the common iliac artery. Commonly, to repair a defect in these branched vessels, a stent graft is provided which, when deployed in the common iliac artery, has a side branch or arm positioned towards the opening to the internal iliac artery and then, if desired, another stent graft can be deployed through the side branch into the internal iliac artery to bypass a diseased portion thereof and restore the blood flow path to the internal iliac artery.

Generally, when deploying an endovascular stent graft into a vessel lumen, it is possible to obtain access to such a lumen from one or both ends of the vessel where necessary, thereby facilitating placement of a graft in the desired portion of the lumen. However, the internal iliac artery, which extends from the common iliac artery below the aortic bifurcation, is a blind vessel because there is no practical way of performing a minimally invasive endovascular procedure into that vessel other than by entry from the common iliac artery.

Access to and introduction of a stent graft into the common and/or internal iliac arteries and successful deployment of a stent graft in such vessels may often depend upon a favorable layout of the arteries and, in many cases, access is difficult. One known approach that has been used includes accessing the target location(s) within the vessels by a contralateral or crossover approach. In other words, a delivery device having a guide wire carried thereon may be first introduced into a common iliac artery and the wire snared and pulled though the delivery device (while the device is still sheathed) from the contralateral side so that it extends across the aortic bifurcation. The wire is often covered by a catheter to allow manipulation of the wire during snaring. In this way, a pathway is created in the vasculature to facilitate the introduction and deployment of a stent graft to the target location in the contralateral internal iliac artery.

As endovascular techniques become more refined, physicians continue to seek novel alternative and simplified approaches to treating diseased vessels, including delivery devices that facilitate introduction and deployment of stent grafts into branched and/or blind vessels that are difficult to access and traverse. For example, accessing the target location(s) within the common and/or internal iliac artery using a low-profile delivery device for placing a stent graft in one or more branched vessels that eliminates the need to snare and pull a pre-loaded guide wire though the sheathed delivery device and over the aortic bifurcation is desirable. A method for introducing a stent graft into the common and/or internal iliac arteries and a delivery device to enable such a method to be practiced is described herein.

While this invention will be generally discussed in relation to a delivery device for a stent graft and method of deployment thereof into a common iliac artery where it is necessary to extend a side branch from a main portion or body of the graft into an internal iliac artery, it is also contemplated that the invention is not so limited and may relate to any body or vessel lumen in which such a deployment is necessary or desired.

SUMMARY

The present disclosure provides a system and method for delivering and deploying an endovascular graft into one or more branched vessels.

In one example, the system comprises a delivery device comprising a pusher catheter having a proximal end portion and a distal end portion and a lumen extending therebetween. A cannula having a proximal end portion and a distal end portion extends longitudinally within the lumen of the pusher catheter and a nose cone dilator is located proximal of the proximal end portion of the cannula. The nose cone may include a proximal tip. The device may further comprise an extension sheath extending from the proximal tip of the nose cone dilator, the sheath having a lumen extending therethrough. A stent graft may be carried on the delivery device. In one example, the stent graft may comprise a main tubular body of a biocompatible graft material defining a main lumen having a proximal end portion and a distal end portion, a side branch extending from the main tubular body, the side branch defining a lumen and being in fluid communication with the main lumen. The stent graft may be configured to be deployed into the vasculature of a patient with the main tubular body being located in the ipsilateral common iliac artery and the side branch being directed towards an internal iliac artery of the common iliac artery. The device may further comprise a pre-loaded guide wire extending through the lumen of the pusher catheter, through the side branch lumen and extend out of the proximal end portion of the main graft body. The guide wire may further extend at least partially through the lumen of the extension sheath.

The system may further comprise a second delivery device. In one example, the second delivery device comprises a second stent graft having a tubular body of biocompatible graft material defining a main lumen carried on a proximal end portion of the second delivery device.

A method for treating a diseased vessel is also described. In one example, the method comprises introducing a delivery device into an ipsilateral common iliac artery. The delivery device preferably comprises a pusher catheter having a proximal end portion and a distal end portion and a lumen extending therebetween, a cannula having a proximal end portion and a distal end portion extending longitudinally within the lumen of the pusher catheter, a nose cone dilator proximal of the proximal end portion of the cannula, an extension sheath extending from the proximal tip of the nose cone dilator, the sheath having a lumen extending therethrough. A stent graft comprising a main tubular body of a biocompatible graft material defining a main lumen having a proximal end portion and a distal end portion, a side branch extending from the main tubular body, the side branch defining a lumen and being in fluid communication with the main lumen, is carried on the delivery device. The stent graft is configured to be deployed into the vasculature of a patient with the main tubular body being located in the ipsilateral common iliac artery and the side branch being directed towards an internal iliac artery of the common iliac artery. A pre-loaded guide wire extends through the lumen of the pusher catheter, through the side branch lumen and extends out of the proximal end portion of the main graft body. The pre-loaded guide wire has a proximal end portion extending at least partially through the lumen of the extension sheath. The method further comprises the step of extending the extension sheath and proximal end portion of the guide wire over the aortic bifurcation and in a distal direction down the contralateral common iliac artery. The method may further comprise the steps of at least partially deploying the stent graft in the ipsilateral common iliac artery and withdrawing the extension sheath from the patient's vasculature. In addition, the method may further comprise. The method of claim 11 further comprise introducing an auxiliary sheath having a lumen into the contralateral common iliac artery, tracking the auxiliary sheath over the pre-loaded guidewire such that the sheath lumen provides a pathway that extends from the contralateral common iliac artery, over the aortic bifurcation, through the proximal end portion of the main graft and through the lumen of the side branch. A second delivery device may be delivered through the pathway defined by the auxiliary sheath lumen, wherein the second delivery device comprises a second stent graft carried on a proximal end portion thereof, the second stent graft comprising a tubular body of a biocompatible graft material. The second stent graft may be positioned within the ipsilateral internal iliac artery and at least partially deployed therein.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows one example of a pre-loaded delivery device for introducing, placing and deploying a stent graft into a patient's vasculature.

FIGS. 2-13 illustrate a portion of a patient's vasculature and an example of the various stages of the introduction, placement and deployment of a stent graft into a common iliac artery and an internal iliac artery.

DETAILED DESCRIPTION

Throughout this specification the terms “proximal” and “proximally” are used for a position or direction towards the patient's heart and the terms “distal” and “distally” are used for a position or direction away the patient's heart. The term “ipsilateral” is used to indicate that the diseased vessel(s) being accessed during a given procedure are on the same side of the body (right or left) as the vascular access device/introducer, while “contralateral” signifies that the vessel(s) of interest are on the opposite side of the body.

The embodiments described below are in connection with systems and methods for the introduction and deployment of an implantable medical device in a vessel, such as endovascular prosthesis, but could also be used for deploying a range of implantable medical devices including, but not limited to, stents, stent grafts, occlusion devices and the like.

Referring to FIG. 1, an example of a stent graft delivery device is shown generally at 2 with a stent graft 4 mounted onto it. During the medical procedure to position and deploy the stent graft 4, the proximal end 6 of the device 2 will travel through the vessel lumen to a desired deployment site. The distal external manipulation section 8 which may include a handle portion, which is acted upon by a user to manipulate the device, remains outside of the patient throughout the procedure. The delivery device 2 is preferably “pre-loaded”, or in other words, before the delivery device is introduced into the patient's vasculature, it is pre-assembled with mechanisms that facilitate graft delivery and deployment already arranged thereon. The delivery and deployment mechanisms may include, for example, one or more guide wires, catheters, sheaths, stent grafts and combinations thereof, which are arranged on and/or are carried by the device 2 and which remain in place during delivery of the stent graft 4 into a patient's vasculature. In one non-limiting example, the delivery device 2 may include one or more mechanism that aid in the placement and deployment of a stent graft 4 in the common iliac artery and/or one or more mechanisms that aid in the placement and deployment of an additional or side branch extension stent grafts in an internal iliac artery in accordance with the systems and methods described herein.

More specifically, as shown in FIG. 1, the device 2 includes a pusher catheter 10 having a proximal end portion 12 and a distal end portion 14. In one example, the pusher catheter 10 has at least one lumen extending between the proximal 12 and distal 14 end portions. A sleeve or sheath 16, which may be operated by a sheath manipulator 18, is preferably mounted co-axially over the pusher catheter 10. In the ready-to-deploy position, the sheath 16 extends proximally to the nose cone dilator 20 and covers a stent graft 4 carried on the device 2. As illustrated in FIG. 1, however, the sheath 16 is withdrawn so that the stent graft 4 is exposed to show detail of the assembly. A handle 22 at the distal end 14 of the pusher catheter 10 enables manipulation of various components of the device 2.

As shown in FIG. 1, a cannula 24 extends through the lumen of the pusher catheter 10, from the distal end 8 of the device to immediately distal of the nose cone dilator 20. A branched stent graft 4 may be retained on the device 2, and, in one example, the proximal end of the graft 26 may be secured to the cannula 24 by a retention arrangement immediately distal of the nose cone dilator 20. The branched stent graft 4 may also be retained at its distal end 28 by another retention arrangement on the device 2. Retention may be by various means, and in one non-limiting example, may include one or more loops or stitches of suture material which are engaged with a trigger wire extending from an aperture (not shown) in the cannula 24. In another example, a trigger wire (not shown) may pierce or be woven through the stent graft 4 directly, thus, retaining the graft against the cannula 24 until the trigger wire(s) is removed. However, it is also contemplated that other types and methods of proximal and/or distal restraint may be used including various diameter reducing ties, fasteners or the like that are suitable for removably securing the stent graft 4 on the device 2. The retaining mechanisms may be placed in any suitable arrangement or location so that the graft 4 is removably secured to the device 2. The proximal and/or distal ends of the stent graft 4 may be released from this retention arrangement by releasing the one or more mechanisms (i.e. releasing a suture and trigger wire or any other type of mechanisms that may be used in combination with or in place of such sutures) during deployment of the graft, thereby facilitating at least partial deployment of the stent graft 4 within a vessel lumen.

The stent graft 4 carried on the device 2 preferably has a substantially tubular main body 30 having a proximal end portion 26 and a distal end portion 28 with a main lumen 32 extending through the main tubular body 30. A side branch 34, also preferably having a substantially tubular body defining a lumen 36, preferably extends from the main body 30 and may be integrally formed with the main body, or alternatively, the side branch 34 may be a separately formed component that is secured to the main body 30 such as by stitching, bonding, adhesive or the like. The lumen 32 of the main body and the lumen 36 of the side branch are preferably in fluid communication. In one example, both the main body 30 and the side branch 34 are constructed from of one or more biocompatible materials including, but not limited to, polyesters, fluorinated polymers and polyurethanes and/or may be made from natural or organic materials. The materials may also be subjected to surface modifications or coatings.

In a preferred example, the stent graft 4 is configured to be deployed into the vasculature of a patient with the main tubular body 30 being located in the common iliac artery and the side branch being directed towards an internal iliac artery of the common iliac artery, although other stent graft configurations for deployment into various other body vessels are also contemplated depending on various factors including, but not limited to the particular vessel(s) being treated and/or the location of a particular damaged or diseased portion of a vessel.

As shown in FIG. 1, an extension sheath 38 extends from the proximal tip 40 of the nose cone dilator 20. The extension sheath 38 is preferably flexible to allow it to be advanced through a patient's vasculature, and at least a portion of the extension sheath is, in one example, curved in a hook or U-shaped configuration. However, the extension sheath 38 may have a variety of shapes and configurations depending on the procedure being performed and the vasculature though which the delivery device is being navigated. A lumen 42 extends through the extension sheath 38, and the sheath may terminate in a proximal tip 44.

The delivery device 2 is preferably pre-loaded with a guide wire 46. This pre-loaded guide wire 46 runs along the length of the delivery device and extends proximally from the proximal end 12 of the pusher catheter 10 and runs outside of the distal end portion 28 of the main graft body, and into the lumen 36 of the side branch 34. The guide wire 46 continues to run proximally through the lumen 36 of the side branch 34, out of the proximal end 26 of the main graft lumen 32 and, in a first “pre-deployment” position, the guide wire 46 extends through the lumen 42 of the extension sheath 38 and terminates at a location near the proximal tip 44 of the extension sheath 38. In other words, the guide wire 46 is contained within the lumen 42 of the extension sheath 38 and conforms to the shape of the extension sheath as the sheath is introduced and advanced though a patient's vasculature. The guide wire 46 and the extension sheath 38 are separate components, however, such that the extension sheath 38 may be removed from a patient's vasculature at some point during a procedure while the guide wire 46 remains in place within the vasculature.

Looking to FIGS. 1 and 5, the device also preferably includes one or more control mechanisms 49 located outside of the patient's body at the distal end portion 8 of the delivery device 2 which allows the physician to manipulate the extension sheath 38 and, at the appropriate time during a particular procedure, release the extension sheath 38 from the delivery device 2 so that the extension sheath can be removed from the vasculature as described herein. One or more additional control mechanisms, such as mechanism 51 which is also preferably located outside of the patient's body as shown in FIGS. 1 and 12, can be acted upon by the physician to manipulate other components of the delivery device. In one non-limiting example, mechanism 51 may be connected to a distal end portion of one or more trigger wires or otherwise interface with the retention mechanism(s) that at least partially restrain and hold the stent graft 4 on the delivery device 2 prior to the final deployment of the graft 4 within the vessel lumen. Manipulation of control mechanism 51 preferably allows the removal of the trigger wire(s) and/or other retention mechanism(s) when it is appropriate or desirable to fully deploy the stent graft 4 in the vessel lumen during a particular procedure.

Now looking at FIGS. 2 through 13, it will be seen that there is schematically illustrated a series of vessels within the human body, including the common iliac arteries 48 and 50 and the respective internal iliac arteries 52 and 54. The systems and methods described herein find particular application in the delivery, placement and deployment of one or more stent grafts therein, although as discussed earlier, the disclosed systems and methods are not restricted to this particular purpose and may be used in a variety of applications as will be appreciated by one of skill in the art.

Turning to FIG. 2, a descending aorta 56 extends down to an aortic bifurcation 58 from which extend common iliac arteries 48 and 50. From each of the common iliac arteries an internal iliac artery 52 and 54, respectively, extends. In most cases, the internal iliac arteries 52 and 54 cannot be practically accessed from their distal ends remote from the junction with the common iliac artery. For illustrative purposes, common iliac artery 48 is shown as having a diseased portion, including an aneurysm 60, although, it will be appreciated that one or both common iliac arteries 48, 50 and/or one or both internal iliac arteries 52, 54 may also include diseased portions that may be treated in accordance with the systems and methods described herein.

As shown in FIG. 2, the introduction of the delivery device 2 is preferably preceded by the placement of a “through wire” 62 within the vasculature of a patient, which provides an “up and over” pathway (i.e. a pathway extending proximally up through the contralateral iliac artery 50, over the aortic bifurcation 58 and distally down the ipsilateral common iliac artery 48). The pathway provided by the through wire 62 may be used to ultimately facilitate the introduction and placement of the delivery device 2 in a desired location with a vessel lumen, such as providing a pathway over which the delivery device 2 may be tracked or extended, for example.

The through wire 62 may be placed in the vasculature by various acceptable methods and techniques, and introduced through various locations. In one non-limiting example, the through wire 62 may be introduced into a femoral artery via a femoral incision (not shown) and extended proximally beyond the aortic bifurcation 58 to the descending aorta 56. The wire may then be snared and pulled from the contralateral side to create the “up and over” pathway. Alternatively, the through wire 62 may be introduced into the vasculature through other locations, including, but not limited to through a brachial puncture (not shown) for placement in a desired location within the iliac arteries. As shown in FIG. 2, a portion of the through wire extends through the lumen of an auxiliary sheath 64 that is positioned in the contralateral iliac artery 50. Placement of the though wire 62 as shown in FIG. 2 by any number of acceptable techniques and methods aids in the introduction of the delivery device into the patient's vasculature as described in further detail below.

As shown in FIG. 3, the device 2 may be introduced into the common iliac artery 48 and advanced over the through wire 62 with the nose cone dilator 20 located near the aortic bifurcation 58. Preferably, the device is advanced so that the extension sheath 38, with the preloaded guide wire 46 enclosed within the lumen of the sheath 38, extends over the aortic bifurcation 58 and is tracked distally through the contralateral iliac artery 50 and through the auxiliary sheath 64 that remains in place in the contralateral iliac artery 50. At this stage, sheath 16, extending proximally up to the nose cone dilator 20, covers the branched stent graft 4 that is carried on the device 2, so that the graft 4 is not visible in FIG. 3. With the device 2 in this position within the lumen of common iliac artery 48, the graft 4 (enclosed within the sheath 16) is preferably adjacent to the opening of the internal iliac artery 52.

As shown in FIG. 4, the sheath 16 has been partially withdrawn (in a distal direction) to expose the branched stent graft 4 so that the sheath 16 is just distal of the distal end 28 of the graft 4. The stent graft 4 is partially unconstrained in that it has been freed from the confines of the sheath 16, but it is still preferably retained by a retention mechanism at one or both of the proximal 26 and distal 28 ends of the stent graft. The graft may also include constraints or diameter reducing ties in the central portion, if desired. Accordingly, the stent graft 4 is not yet in a fully expanded condition within the lumen of the common iliac artery 48. It can be seen that the stent graft 4 carried on the device 2 is pre-loaded in one exemplary arrangement. More specifically, the device 2, with the stent graft 4 carried thereon, is pre-loaded as described above in connection with FIG. 1 such that the pre-loaded wire 46 extends proximally through the pusher catheter 10, through the lumen 36 of the side branch 34, out of the proximal end 26 of the main graft body 4 and through the lumen 42 of the extension sheath 38. However, it is also contemplated that the device can be pre-loaded in a variety of acceptable ways that may not only aid in the placement and deployment of the main stent graft 4 in the common iliac artery but which also ultimately facilitates the placement of one or more additional stent grafts into the branched vessels, including, but not limited to, the internal iliac artery.

FIG. 5 shows an example of the next stage a graft delivery and deployment sequence where the extension sheath 38 may be removed from the patient's vasculature. (Although, it is also contemplated that the steps illustrated in FIGS. 4 and 5 could be reversed, such that the extension sheath 38 may be removed before graft 4 is unsheathed.) In one example, the control mechanism 49 located outside of the patient's body at the distal end portion 8 of the delivery device 2 can be manipulated by the physician, such as to release the extension sheath 38 from the delivery device 2 so that the extension sheath can be separated from the device and removed from the vasculature. The extension sheath 38 may be withdrawn distally through the auxiliary sheath 64 (as shown by the arrow in FIG. 5) from the contralateral iliac artery 50, although, if desired or necessary, the extension sheath 38 may be withdrawn by other acceptable techniques and methods, and/or withdrawn through other locations. With the extension sheath 38 removed, the pre-loaded wire 46 preferably remains in place as shown in FIG. 5 such that it extends through the delivery device 2 (in the ipsilateral iliac artery 48), out the proximal end 26 of the main graft body 4, over the aortic bifurcation 58 and distally through the auxiliary sheath 64 (in the contralateral iliac artery 50).

In the example described above, at this stage, the pathway provided by the pre-loaded guide wire 46 is essentially parallel to the “up and over” pathway provided by the through wire 62, and as shown in FIG. 5, both the pre-loaded wire 46 and the through wire 62 each have terminal ends that can preferably be accessed on the outside of a patient's body on one or both of the ipsilateral and/or contralateral sides 48, 50. Wire 46 may allow a physician to introduce, manipulate and place a stent graft at a desired location within the patient's vasculature, such as in a common iliac artery, while control of both wires 46, 62 may assist in the introduction of additional stent grafts in a branched and/or side vessel.

At this stage, an additional or “contralateral” sheath 66 is introduced into the patient's vasculature, which is preferably intended to facilitate the delivery and deployment of an extension graft into the ipsilateral internal iliac artery 52. Alternatively, sheath 64 may be used instead of using an additional sheath 66 if sheath 64 has the appropriate properties, including, but not limited to being larger than the extension sheath that is introduced therethrough (as described in detail below) and is long enough to reach the contralateral iliac artery 50.

As illustrated in FIG. 6, a contralateral sheath 66 may be extended proximally through the contralateral iliac artery 50, over the aortic bifurcation 58, into the proximal end 26 of the main graft body 4 and through the lumen 36 of side branch 34. This may be accomplished by tracking the contralateral sheath 66 through the lumen of the auxiliary sheath 64 and over the pathway provided by the pre-loaded guide wire 46 (shown in FIG. 5) which is still in place in the iliac arteries 48, 50. As FIG. 6 best shows, the contralateral sheath 66 is extended until the tip 68 of the sheath 66 emerges from the distal end of the side branch 34 such that the tip 68 adjacent to the opening of the internal iliac artery 52. Alternatively, as FIG. 6 illustrates, the original through-wire 62 may be pulled in a proximal direction and advanced up into the infrarenal aorta 56, as shown by the dashed line in FIG. 6. With wire 62 extending proximally into the aorta 56 rather than distally through the contralateral sheath 66 (in contralateral iliac artery 50), space is freed up in the auxiliary sheath 64 (which would otherwise be taken up by the wire 62) to make room in the sheath 64 for the contralateral sheath 66 and auxiliary catheter 70 to be advanced therethrough.

Auxiliary catheter 70, with an auxiliary wire 72 extending longitudinally through the lumen thereof, may be advanced all the way through the contralateral sheath 66 for cannulation of the internal iliac artery 52, as shown in FIG. 6.

The original auxiliary wire 72 that extends through auxiliary catheter 70 and that is initially introduced into the internal iliac artery 52 (as shown in FIG. 6) may be replaced with an alternative, stiffer auxiliary wire 74, if desired, which may be extended further, along with the auxiliary catheter 70, into the internal iliac artery 52, as illustrated in FIG. 7.

With the stiffer auxiliary wire 74 extended into and placed in a desired location in the internal iliac artery 52, the auxiliary catheter 70 can be withdrawn from the patient's vasculature as shown in FIG. 8. In one example, the auxiliary catheter 70 can be pulled distally through the contralateral sheath 66 (through the contralateral iliac artery 50) and removed from the vessel. The auxiliary wire 74 remains in place, however, after the auxiliary catheter 70 has been removed from the patient's body. At this stage, a second delivery device 76 can be tracked over the pathway provided by the auxiliary wire 74. The second delivery device 76 preferably carries an additional leg or “extension” stent graft 78 that is intended for delivery and deployment within the internal iliac artery 52, although extension graft 78 may be deployed within any portion of the patient's vasculature as necessary or desired. The extension graft 78 is preferably carried on a proximal end portion of the second delivery device 76, while a distal external manipulation portion 80 remains outside of the patient's body and allows a physician to manipulate the second delivery device 76 within the patient's vasculature. The extension graft 78 is preferably covered by an appropriately sized sheath 82 (so that the extension graft 78 is not visible in FIG. 8). The second delivery device 76 is tracked over the auxiliary wire 74 until the proximal end portion or tip 84 of the device 76 is extended beyond tip 68 of the contralateral sheath 66, into the internal iliac artery 52, and the extension graft 78 positioned in a desired location therein. Preferably, the extension graft 78 is positioned in the internal iliac artery 52 so that it extends both proximally and distally away from the location of an aneurysm, therefore, spanning and bypassing the diseased portion of the vessel.

At this stage, the contralateral sheath 66 can be partially withdrawn, as shown in FIG. 9. In one example, the contralateral sheath 66 may be pulled distally from the contralateral side 50 until the tip 68 of the contralateral sheath 66 is located approximately adjacent to the proximal end portion of the side branch 34. At this time, the pre-loaded wire 46 may also be removed from the patient's vasculature. Preferably, this may be accomplished by pulling the pre-loaded wire 46 distally through the contralateral sheath 66 (within the lumen of the contralateral common iliac artery 50) and out of the patient's body. However, the pre-loaded wire 46 may also be removed in other suitable ways including through the delivery device 2 on the ipsilateral side 48.

As shown in FIG. 10, the stent graft 4 and/or the extension graft 78 may be deployed within the lumen of the internal 52 and common iliac 48 arteries, respectively. For example, the sheath 82 covering the extension graft 78 on the second delivery device 76 may be withdrawn by pulling the sheath 82 distally through the contralateral sheath 66 for removal from the patient. At this time, the second delivery device 76 may also be removed from the patient's vasculature by pulling the second delivery device 76 distally through the contralateral sheath 66 (within the common iliac artery 50). In addition, the main sheath 16 (which covered the main stent graft 4 prior to delivery and deployment) may be withdrawn by pulling the sheath 16 distally from the ipsilateral common iliac artery 48 as shown in FIG. 11. After removal of the main sheath 16 from the main graft 4 and the extension sheath 82 from the extension graft 78, the grafts 4, 78 are at least partially deployed within the vessels 48, 52. To fully deploy the main 4 and extension grafts 78, the retention mechanism(s) that releasably retain the proximal end 26, the distal end 28 (or both ends) of the stent graft 4 on the delivery device 2, if present, are preferably removed.

To accomplish removal of the retention mechanism(s) when it is appropriate or desirable to fully deploy the stent graft 4 in the vessel lumen 48 during a particular procedure, the additional control mechanism 51 as shown in FIG. 12 for example, can be acted upon by the physician to manipulate and remove one of the trigger wire(s) 86 and/or other retention mechanism(s). Once the retention mechanism(s) (not shown) have been removed from the proximal 26 and/or distal ends 28 of the stent graft 4 (and/or from extension graft 78 if such retention mechanisms are present in the second delivery device 76), the respective grafts 4, 78 may be radially expanded or deployed within the respective vessels 48, 52.

In one example, a “self-expanding” stent expands primarily based on its own expansive force without the need for further mechanical expansion. More particularly, a stent made of a shape-memory alloy such as Nitinol may allow the stent graft 4, 78 to return to a predetermined expanded configuration upon removal of a sheath (e.g., sheath 16 or 82) or other mechanism that maintains the stent graft 4, 78 in its compressed, pre-deployment configuration. In another example, stents made of materials such as stainless steel may expand on their own accord once released from constraints holding them in their compressed state. Alternatively, a stent graft 4, 78 may require further manipulation, mechanical or manual expansion, such as by balloon expansion by the user. In either case, it is contemplated that the stent graft 4, 78 may expand or deploy only partially within the vessel lumen after removal of any retention mechanisms, such that additional expansion of the stent graft 4, 78 may be desired or required, at which time the user may implement various known and acceptable techniques to fully deploy the graft 4, 78 in the common 48 and/or branched vessel 52. Such fully deployed stent grafts 4 and 78 are illustrated in exemplary FIG. 13.

As shown in FIG. 13, the leg extension graft 78 preferably extends from the side branch 34 of the stent graft 4 into the internal iliac artery 52. Proximal and/or distal retention (not shown) of graft 78 may include the same or similar retention mechanisms as those described above in connection with the retention of stent graft 4 on delivery device 2, such that graft 78 may be retained on the second delivery device 76 in a manner similar to that of graft 4. Of course, other types and methods of proximal and/or distal restraint of extension graft 78 may be used including various diameter reducing ties, fasteners or the like that are suitable for removably securing the extension graft 78 on the further delivery device 76. Proximal and/or distal retention of extension graft 78 may be in addition to or in combination with sheath 82 which also secures the graft 78 to second delivery device 76 and holds it in a radially inwardly compressed “pre-deployment” condition.

Following graft deployment, the delivery device 2 can also be withdrawn from the patient's body, if desired, although in some situations, it may be desirable to leave one or more components, such as pusher catheter 10 and/or the sheath 16 in position within the common iliac artery 48 so that further introduction and deployment of another stent graft into the aorta 56, such as a bifurcated stent graft, can be facilitated through the pusher 10 and/or sheath 16.

Thus, the pre-loaded delivery device with an extension sheath as described herein effectively and efficiently facilitates the introduction, placement and deployment of a stent graft into one or more branched vessels, including, but not limited to a common iliac artery and an internal iliac artery extending therefrom, in order to treat and/or restore patency to one or both of such vessels.

Throughout this specification, unless the context requires otherwise, the words “comprise” and “include” and variations such as “comprising” and “including” will be understood to imply the inclusion of an item or group of items, but not the exclusion of any other item or group items.

While various examples of the invention have been described, it will be apparent to those of ordinary skill in the art that many more examples and implementations are possible within the scope of the invention. Furthermore, although various indications have been given as to the scope of this invention, the invention is not limited to any one of these but may reside in two or more of these combined together. Accordingly, the invention is not to be restricted except in light of the attached claims and their equivalents. 

The invention claimed is:
 1. A system for the delivery and deployment of an endovascular graft comprising: a. a delivery device comprising: i. a pusher catheter having a proximal end portion a distal end portion and a lumen extending there between, and a proximal end opening; ii. a cannula having a proximal end portion and a distal end portion extending longitudinally within the lumen of the pusher catheter; iii. a nose cone dilator proximal of the proximal end portion of the cannula, the nose cone dilator having a proximal tip; iv. an extension sheath extending from the proximal tip of the nose cone dilator, the extension sheath having a lumen extending there through, wherein a portion of the extension sheath has a U-shaped configuration; b. a stent graft carried on the delivery device, the stent graft comprising: i. a main tubular body of a biocompatible graft material defining a main lumen having a proximal end portion, a distal end portion, a distal end opening; ii. a side branch extending from the main tubular body, the side branch defining a lumen and being in fluid communication with the main lumen, whereby the stent graft is configured to be deployed into the vasculature of a patient with the main tubular body being located in the ipsilateral common iliac artery and the side branch being directed towards an internal iliac artery of the common iliac artery; c. a pre-loaded guide wire extending through the lumen of the pusher catheter, exiting the proximal end opening of the pusher catheter distal to the distal end opening of the main tubular body, extending entirely outside of the distal portion of the main tubular body along side the main tubular body and entering the main lumen of the main tubular body through the lumen of the side branch and extending out of the proximal end portion of the main tubular body, the pre-loaded guide wire further extending at least partially through the lumen of the extension sheath.
 2. The system of claim 1 wherein the extension sheath is flexible and adapted to be manipulated though the contours of a vessel lumen.
 3. The system of claim 1 wherein the stent graft is secured to the proximal end portion of the cannula.
 4. The system of claim 1 wherein the delivery device further comprises a mechanism for manipulating the extension sheath.
 5. The system of claim 1 further comprising a second delivery device, the second delivery device comprising a second stent graft carried on a proximal end portion of the second delivery device, the second stent graft comprising a tubular body of a biocompatible graft material defining a main lumen.
 6. The system of claim 5 wherein the second delivery device is sized and configured to be advanced through the proximal end portion of the main tubular graft body and into the lumen of the side branch.
 7. The system of claim 5 wherein the second stent graft carried by the second delivery device is configured to be positioned within the internal iliac artery.
 8. The system of claim 5 further comprising a sheath mounted coaxially over at least a portion of the second stent graft.
 9. The system of claim 1, wherein the greatest diameter of the extension sheath is less than the diameter of the proximal tip of the nose cone dilator.
 10. A method for treating a diseased vessel, the method comprising: a. introducing a delivery device into an ipsilateral common iliac artery, the delivery device comprising: i. a pusher catheter having a proximal end portion, a distal end portion and a lumen extending there between, and a proximal end opening; ii. a cannula having a proximal end portion and a distal end portion extending longitudinally within the lumen of the pusher catheter; iii. a nose cone dilator proximal of the proximal end portion of the cannula, the nose cone dilator having a proximal tip; iv. an extension sheath extending from the proximal tip of the nose cone dilator, the extension sheath having a lumen extending there through, wherein a portion of the extension sheath has a U-shaped configuration; v. a stent graft carried on the delivery device, the stent graft comprising a main tubular body of a biocompatible graft material defining a main lumen having a proximal end portion, a distal end portion, a distal end opening, a side branch extending from the main tubular body, the side branch defining a lumen and being in fluid communication with the main lumen, whereby the stent graft is configured to be deployed into the vasculature of a patient with the main tubular body being located in the ipsilateral common iliac artery and the side branch being directed towards an internal iliac artery of the common iliac artery; vi. a pre-loaded guide wire extending through the lumen of the pusher catheter, exiting the proximal end opening of the pusher catheter distal to the distal end opening of the main tubular body, extending entirely outside of the distal portion of the main tubular body along side the main tubular body and entering the main lumen of the main tubular body through the side branch lumen and extending out of the proximal end portion of the main tubular body, the pre-loaded guide wire having a proximal end portion extending at least partially through the lumen of the extension sheath, b. extending the extension sheath and proximal end portion of the pre-loaded guide wire over the aortic bifurcation and in a distal direction down the contralateral common iliac artery.
 11. The method of claim 10 further comprising at least partially deploying the stent graft in the ipsilateral common iliac artery.
 12. The method of claim 11 further comprising withdrawing the extension sheath from the patient's vasculature.
 13. The method of claim 12 wherein the extension sheath is withdrawn from the contralateral side.
 14. The method of claim 11 further comprising: a. introducing an auxiliary sheath having a lumen into the contralateral common iliac artery, and b. tracking the auxiliary sheath over the pre-loaded guidewire such that the sheath lumen provides a pathway that extends from the contralateral common iliac artery, over the aortic bifurcation, through the proximal end portion of the main graft and through the lumen of the side branch.
 15. The method of claim 14 further comprising: a. introducing a second delivery device through the pathway defined by the auxiliary sheath lumen, the second delivery device comprising a second stent graft carried on a proximal end portion thereof, the second stent graft comprising a tubular body of biocompatible graft material, b. positioning, the second stent graft within the ipsilateral internal iliac artery, c. at least partially deploying the second stent graft in the ipsilateral internal iliac artery.
 16. The method of claim 15 further comprising removing the auxiliary sheath and second delivery device from the patient's vasculature. 